CONFIDENTIAL

CARE CORNER Educational Therapy Service

Blk 149 Toa Payoh Lor 1 #01-973 Singapore 310149

Blk 414 Tampines St 41 #01-297 Singapore 520414

Questionnaire on Child Development

Child’s Name: / Age: / School Level:
Parent’s Name: / Date: / Tel / Hp No.:

The following questions are intended to help us have a better understanding of your child’s condition. Your honest answers to each question will help us determine what course of action to take in order to help your child with his or her learning difficulties. Please answer to the best of your knowledge.

Please put an “X” in the appropriate boxes.

Developmental & Medical History / Yes / No
  1. Is there any history of learning difficulties in your immediate family?
If “Yes,” please indicate: _
  1. Were there any medical problems during the pregnancy?

  1. Was the birth process unusual or prolonged in any way?
If “Yes,” please indicate: Caesarean / forceps /
ventouse (suction) / others: _
  1. Was your child born early or late for term (more than 2 weeks early or more than 10 days late)

  1. Did your child weigh less than 2.3kg (5lbs) when he or she was born?

  1. Did your child have any difficulty feeding in the first weeks of life, or in keeping food down?

  1. Was your child extremely demanding in the first 6 months of life? ( e.g cried easily, needed constant attention, fidget constantly etc.)

  1. Did your child miss out the crawling stage?

  1. Was your child late at learning to walk (16 months or later would be considered late)?

  1. Was your child late at learning to talk (2-3 word phrases at 18 months or later would be considered late)?

  1. Did your child have difficulty in learning to dress himself or herself, for example, do up buttons or tie shoelaces beyond the age of 6-7 years?

  1. Did your child have an adverse reaction to any of his or her vaccinations?

  1. Did he or she suck his or her thumb up to the age of 5 years or beyond?

  1. Did your child continue to wet the bed, albeit occasionally, above the age of 5 years?
/ Yes / No
  1. Does your child suffer from travel sickness or motion sickness?

  1. Did your child find it very difficult to learn to tell the time from a traditional (as opposed to digital) clock? ( e.g encounter difficulty in reading an analogue clock above the age of 7 years old)

  1. Did your child have an unusual degree of difficulty learning to ride a bicycle?

  1. Did your child suffer from frequent ear, nose, throat or chest infections at any time in development?

  1. In the first 3 years of life, did your child suffer from any illnesses involving extremely high temperatures, delirium or convulsion?

  1. Does your child (above 5 years old) have difficulty catching a ball?

  1. If there is a sudden unexpected noise, does your child over-react?

  1. Does your child suffer from allergies?

  1. Does your child have difficulty sitting still on a chair for more than 5 minutes?

  1. Does your child have reading difficulties?

  1. Does your child have handwriting difficulties?

  1. Does your child have copying difficulties?.

  1. Does your child encounter letter reversals when reading or writing?

  1. Does your child have difficulties understanding maths concepts?

  1. Does your child have problems with speech?

  1. Has your child ever suffered from any serious illness/health condition (e.g. seizures/fits, heart problem, asthma)?
If “Yes”, please indicate:
  1. Has your child been formally assessed / diagnosed?

If yes, your child was:
Diagnosed by: Psychologist / Psychiatrist / Paediatrician / Others:
Diagnosed with: ADHD / Autism (ASD) / Dyslexia / Others:
Diagnosed at: KKH / NUH / IMH-CGC / Others: :

Educational Background

  1. Name of School:
  1. Primary School Results:

School Level / For P5/P6 ONLY / Pass / Fail / Marks (/total)
English / Standard/Foundation
Mathematics / Standard/Foundation
  1. What do your child’s teachers/tutors say about him/her? (e.g. day-dreaming, unable to sit still, etc)

Pre-school teacher(s):

Primary school teachers(s):

Tutor(s):

  1. Is your child enrolled in any learning support program in school? Yes/No

If yes, please provide details (e.g LSP, EIPIC, ICCP, DSP):

Please provide details of any remedial or specialized services (outside normal school curriculum) your child has received or is receiving to help in his learning:

Name/Organisation / Date Started
Month/Year / Date Ended
Month/Year
English Tuition (Primary Level) / / / /
Maths Tuition (Primary Level) / / / /
Preschool Phonics/Reading Program / / / /
Psychological Assessment / IQ Test / / / /
Psychiatrist/Pediatrician Consultation / / / /
Speech/Language Therapy / / / /
Occupational Therapy / / / /
Others (pls specify) / / / /

If you have any written reports from these professionals, please provide us a copy. If there are no reports, please indicate their comments/assessments of your child:

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